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Accurate Cause of Death Reporting
Patients often have multiple conditions contributing to death. Documenting the conditions on the death certificate requires basic training. Below, we outline the steps required. More detail can be found on the Cause of Death Quality page.
- The cause of death should reflect your medical opinion as based on the medical record.
- In Part I, document the complete chain of events that best explains why this patient died. The last item is the underlying cause that began this sequence.
- In Part II, document other conditions that contributed to death. Be specific and complete. For example, if a patient died of “sepsis”, include the medical conditions that predisposed him or her to develop infection. You may qualify conditions with “probable”, “undetermined”, “presumed”, etc, if you are uncertain.
Part I Line A, Immediate Cause of Death
- Indicate what happened right before the patient died – the condition that led to cardio/pulmonary/respiratory arrest. Examples: Proteus mirabilis sepsis, congestive heart failure, liver failure, upper gastrointestinal hemorrhage, left lower lobe pneumonia.
Part I Lines B—D, Intermediate and Underlying Causes of Death
- Outline the sequence of condtions that led to line A. Depending on the complexity of the case, you will almost always use line B and you will often need additional lines (C—D).
- Line B: Indicate how this patient came to have the condition in line A. if proteus mirabilis sepsis is on line A, indicate its cause on line B (e.g., infected sacral decubitus ulcer).
- Lines C and D: Continue backward in time. Specify, to the best of your knowledge, what led to the preceding line (e.g., line C: complications of remote cerebral infarction; line D: atherosclerotic vascular disease).
- The last line should be the underlying cause that is NOT the result of another condition. Paraplegia, hypotension, and renal failure would not be underlying causes because you can specify further why they developed.
- Some appropriate underlying causes are chronic medical conditions. Without them, death would not have occurred at the same time or in the same manner (e.g., cerebrovascular disease, essential hypertension, diabetes mellitus, dementia).
Part II, Other Significant Conditions
- Patients often have multiple medical conditions. Use Part II to list contributing conditions that were not a part of the sequence in Part I.
- A patient with a history of poorly controlled hypertension and a prior positive stress test dies of an acute MI.
Line 1A: Acute myocardial infarction, 1B: Atherosclerotic coronary artery disease, 1C: Essential hypertension
- A patient with liver cirrhosis from chronic alcohol abuse dies of an upper gastrointestinal bleed.
Line 1A: Upper gastrointestinal bleed, 1B: Ruptured esophageal varices, 1C: Liver cirrhosis, 1D: Chronic alcohol abuse
- A patient with a history of emphysema is hospitalized for community-acquired klebsiella pneumonia and dies.
Line 1A: Community-acquired klebsiella pneumonia, 1B: Emphysema, 1C: Smoking
- A patient with Parkinson’s disease is admitted for Gram negative pneumonia and dies in the ICU after the family decides to withdraw ventilator support following a prolonged period of respiratory failure.
Line 1A: Gram negative pneumonia, 1B: Parkinson’s disease.
Download a PDF version of this webpage.
For more examples refer to the Centers for Disease Control Physicians’ Handbook on Medical Certification of Death (PDF).